Eating Disorders Come in All Shapes and Sizes

By: Jennifer L. Gaudiani, MD, CEDS, FAED (www.gaudianiclinic.com)I’m an internal medicine physician who cares for patients with eating disorders and disordered eating, of all shapes and sizes, all genders, and all ages, in my outpatient clinic. I’m struck by how common it is for my patients to confide in me that they don’t feel they are “sick enough” to warrant their friends’ and family’s worry, their need to have a multi-disciplinary team, or to change their behaviors. That feeling of not being “sick enough” is part of the mental illness. People with the most remarkable insight about just about everything else can utterly lack (or distort) insight into the medical and psychological issues that arise from their eating disorder.

This denial doesn’t just emerge from their eating disorder, though. The medical system is deeply at fault too. Doctors and other medical practitioners have for years been bringing their weight stigma and size bias to their patients. The woman in a larger body who has developed critically unhealthy disordered eating patterns gets praised for weight loss in the doctor’s office. The young man who only meant to seek a healthier lifestyle, but fell into increasingly orthorexic habits and now finds his life controlled by anxiety over so-called clean eating, is lauded for his perfect health and willpower. The trans man with binge eating disorder is never even asked screening questions for an eating disorder, but simply gets a stern talking-to about the need to diet, exercise, and lose weight (not to mention the doctor’s office often doesn’t get his pronouns right, and their paperwork is cis-biased).

The fact is that eating disorders come in all shapes and sizes. Contrary to popular belief, the vast majority of people with eating disorders are not living at a low body weight. There is no one measurement—a weight, a laboratory value, a vital sign—that makes someone sick enough to seek treatment and recovery. I take care of patients across the size and weight spectrum, and I can tell you: you cannot tell whether someone is healthy or unhealthy by the size and shape of their body. Malnutrition can exist in people with anorexia nervosa and low body weight, of course, but it can also develop in someone who has a “normal” body weight and has been restricting or purging, or in someone in a larger body who has lost weight rapidly. The diagnosis “atypical anorexia nervosa” describes patients who suffer from all of the fears, distortions, and restrictive eating habits of someone with anorexia nervosa, but doesn’t happen to have a body weight that is formally low for their height. Patients with anorexia, bulimia, binge eating disorder, ARFID, atypical anorexia nervosa, and all points in between can become dangerously medically ill from their eating disorder, with devastating psychological consequences as well.

So please: if you have an eating disorder, regardless of your body size and shape, know that you are sick enough for help. You can find relief from the torment, with its promises of happiness and confidence that never materialize. Society, and the medical establishment in particular, have endless work to do on size stigma and weight bias. A Health At Every Size (HAES) philosophy, which I wholeheartedly subscribe to, is applicable to every individual. Your therapist can help you learn to give yourself compassion for the treatment you endure as a result of society’s biases. Your dietitian can help you learn to nourish yourself adequately and without limitations. You are sick enough, just as you are.